376 IJSR - INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH
Volume : 5 | Issue : 5 | May 2016 • ISSN No 2277 - 8179 | IF : 3.508 | IC Value : 69.48
Research Paper
Medical Science
Mohammed Bilal MD ,Postgraduate student, Department of Paediatrics , A J Institute of Medical Sciences , Mangalore.
Maternal and Neonatal Factors Causing Thrombocytopenia in Neonates Admitted
To Nicu During 2013-2014
KEYWORDS :
ABSTRACT
Background : Thrombocytopenia is the most common hematological abnormality which is encountered in the neonatal intensive care unit (NICU). The incidence in neonates varies greatly, depending upon the population stud- ies. According to the frequency of thrombocytopenia and its complications, this study was performed on neonates admitted to A.J Institute of Medical Sciences-NICU from August 2013-August 2014.Materials and Methods : In a retrospective study, 250 neonates who were admitted to NICU were enrolled in the study. They were categorized to three groups regarding platelet count: mild, moderate and severe thrombocytopenia. Incidence of thrombocytopenia was determined and contribution of variables such as sex, gestational age, intrauterine growth retardation, asphyxia, sepsis, necrotizing enterocolitis, blood group, placental insufficiency in Gestational Diabetes Mellitus (GDM) and hypertension (HTN) were analyzed.
Results : Neonatal thrombocytopenia was found in 91(36.4%) of 250 subjects, consisted of 77.3% early onset and 22.7% late onset, which most of them had mild and moderate thrombocytopenia. Thrombocytopenia was associated with sepsis, intrauterine growth retardation sepsis, asphyxia, Gestational Diabetes Mellitus, maternal hypertension and prematurity. There was no relation between occurrence of thrombocy- topenia and gender.
Conclusion : The incidence of neonatal thrombocytopenia was 36.4 %. Significant maternal risk factors that lead to thrombocytopenia were Hypertension and preeclampsia, while risk factors of neonates were asphyxia, sepsis and Intra Uterine Growth Retardation.
Bharath Raj Professor, Department of Paediatrics , A J Institute of Medical Sciences , Mangalore.
Ashvij Shreyan Neonatologist, Department of Paediatrics , A J Institute of Medical Sciences , Mangalore.
Introduction
Neonatal thrombocytopenia (platelets <150 ×109/litter) is one of the most common hematological abnormalities in neonates occurring in 1 to2% of healthy term neonates. The preterm or sick neonates tend to develop thrombocytopenia. Among these neonates, the incidence of thrombocytopenia is 18 to 35% (1, 2).
Of neonates admitted to neonatal intensive care units (NICUs), the platelet count drops below 150 ×109/L in one in four babies and to below 50 × 109/L in one in twenty (3). A large popula- tion studies showed that more than 98% of term neonates born to mothers with normal platelet counts have platelets above 150
× 109/L at birth (4, 5). There is a newer classification of Neonatal thrombocytopenia (NT) based on the timing of onset of throm- bocytopenia (early, within 72 h of birth versus late, after 72 h of life). These are more useful for neonatal clinicians and will help to facilitate systematic studies to improve the management of NT. Early onset thrombocytopenia is commonly associated with pregnancy complications such as intrauterine growth restric- tion, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), maternal diabetes or drug use. Clinically, the most common cause of severe early NT is known as neonatal al- loimmune thrombocytopenia purpura (NAITP). However, NAITP accounts for only a small proportion (<5%) of early NT overall.
NT occurs in a large proportion of preterm infants, although the thrombocytopenia is self-limiting. It usually disappeares within 10 days (6,7). The most common causes of late NT are sepsis and necrotizing enterocolitis (>80% of cases) (8,9). This form of NT which usually develops very rapidly over 1 to 2 days, is of- ten very severe (platelets <30 × 109/L) and takes 1 to 2 weeks to recover. Such babies frequently require repeated platelet trans- fusion (8). In most cases, neonatal thrombocytopenia is mild to moderate and can be resolved without intervention.
Life-threatening bleeding or intracranial hemorrhage (ICH) with a high risk of neurodevelopmental impairment may oc- cur in severe thrombocytopenia (platelets <50 ×109/L). Alloim- mune thrombocytopenia is associated with a comparatively high bleeding risk. Late onset thrombocytopenia is typically more severe than early onset disease and bleeding is more common (10). Thus, appropriate diagnostic and therapeutic management is necessary to prevent death or neurological sequelae in the
severely thrombocytopenic neonate. Hence, current study was undertaken to evaluate the prevalence and causes of thrombocy- topenia in neonates.
Materials and Methods
A retrospective study was conducted on 250 neonates who ad- mitted to NICU A.J Institute of Medical Sciences,Mangalore.
Blood samples were obtained for platelet (PLT) counts and preparation of blood smear slides. Informed consent forms were obtained from mothers of neonates with thrombocytopenia.
These forms included maternal and neonatal information.Ma- ternal information were about diabetes, hypertension, eclamp- sia and Preeclampsia, autoimmune disease, drug history during pregnancy and RH blood groups. Neonatal information were about gestation age, IUGR (intera uteruine growth retardation), asphyxia, sepsis, RH blood groups, chief complain and final diag- nosis during admission. PLT counting was performed on ethyl- ene diamine tetra acetate- anticoagulated blood with a standard automatic blood cell counter.
Thrombocytopenia was defined as PLT counts of lower than 150
× 109 per L, whereas moderate and severe thrombocytopenia was defined as less than 100 × 109 and fewer than 50 × 109 per L .Early thrombocytopenia was defined from birth to 72hr and late after 73hr of birth.
Statistical Analysis
The data was summarized and analyzed using SPSS 14.0 statis- tical software. Student’s t-test and chisquare test were used to analyze. The results were expressed as means and standard de- viations. A Pvalue of less than 0.05 was taken as significant.
Results
We recorded that, during the 1-year period, 250 neonates were admitted at the NICU of A.J Institute of Medical Sciences. Ninety one (36.4%) of cases were thrombocytopenia. Ninety one blood samples were suitable for the study, representing 51(56%) of neo- nates were female and 41(45%) male. Forty eight cases (52.7%) of patient had mild and 40 cases (43.9%) moderate and 3 (3.29%) of the neonates were severe thrombocytopenia. 70 (77.3%) pa- tients were with early onset and 21(22.7%) cases were with late
IJSR - INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH 377 Volume : 5 | Issue : 5 | May 2016 • ISSN No 2277 - 8179 | IF : 3.508 | IC Value : 69.48
Research Paper
onset of thrombocytopenia. Thirty eight (54.2%) of with early on- set thrombocytopenia were mild and 32(45.7%) were moderate.
None of them was severe thrombocytopenia.
In the late thrombocytopenia group, 42(49.4%) were mild and 14(66.7%) moderate, and 3(14.3%) were severe thrombocyto- penia. (P-value=0.112) The most common maternal factor was maternal hypertension (46.4%) and the most common neonatal factor was sepsis. Thrombocytopenia was present in 56(61.5%) of preterm and 35(38.4%) of term neonates.
MATERNAL RISK FACTOR
FREQUENCY
N %
HYPERTENSION 13 46.4
GESTATIONAL DIABETES
MELLITUS 9 32.1
GDM+HYPERTENSION 3 3.6
ECLAMPSIA 2 7.1
ITP 1 3.6
NEONATAL RISK FACTOR
FREQUENCY
N %
SEPSIS 23 31.9
IUGR 15 20.8
ASPHYXIA 10 13.9
ASPHYXIA+IUGR 5 6.9
SEPSIS+IUGR 2 2.8
ASPHYXIA+SEPSIS 1 1.4
NEC 2 2.8
ABO 3 4.2
OTHER 11 15.3
Discussion
Thrombocytopenia affects 22 to 35% of infants admitted to the neonatal intensive care unit. Multiple diseases can cause neo- natal thrombocytopenia and these can be classified as that in- ducing early thrombocytopenia (≤72 h of life) and those induc- ing late-onset thrombocytopenia (N≥72 h) (11).The incidence of thrombocytopenia in neonates varies significantly, depending on the population studied. In this review, we found 91 (36.4%) neo- nates in NICU that were thrombocytopenic. In a similar study which was conducted by Henry E and coworkers on 807 neonate admitted in NICU of MC Master University, 22% of neo- nates were thrombocytopenic(12).
On the other hand, in a study that performed by Naguri MH and coworkers on 258 neonates in NICU, 70% was thrombo- cytopenic. In an other study, in Nigeria by Jeremiah Z and coworkers on 132 neonates that admitted in NICU, 53% were thrombocytopenic (14). But in another study in Indonesia the incidence of thrombocytopenia was lower. In this study that was conducted by Kusamsari N and coworkers 12% of neonates in NICU were thrombocytopenic (15). In our study, 77.3% of neonates were early onset, and 22.7% were late on- set. This is similar to study of Jeremiah Z et al. In their results 84.4% were early onset and 15.6% late onset (14). In contrast with finding of Henry E, our investigation showed that 52.7%
of neonates had mild thrombocytopenia, and 43.9% had mod- erate and , 3.2% of them had severe thrombocytopenia. In
their study, 42% of neonates had mild thrombocytopenia, 38%
and 20% of them had moderate and sever thrombocytopenia, respectively. Compared to their findings, the number of pa- tients with severe thrombocytopenia was lower in our study (12). Similar to other studies we did not find any significant differences in the incidence of thrombocytopenia in both gen- ders (16,17,18,19).
This study showed, the most common maternal factors were hypertension and diabetes, that caused early onset throm- bocytopenia while neonatal factors were asphyxia, sepsis and IUGR .Although NEC had low frequency, it could cause severe thrombocytopenia. This is similar to finding of Rob- ert I et al. They reported hypoxia, diabetes, hypertension and IUGR which caused early onset thrombocytopenia, and ABO incompatibility and NEC as late onset thrombocytope- nia (18).
Conclusion
Neonatal thrombocytopenia is a common clinical problem in NICU. We ensure accurate diagnosis and to determine the most maternal and neonatal factors can reduce neonatal mortality and morbidity.
References
1. Roberts IA, Murray NA. Neonatal thrombocytopenia.CurrHematol Rep 2006;5(1):55-63.
2. Ferrer-Marin F, Liu ZJ, Gutti R, Sola-Visner M. Neonatal thrombocytopenia and megakaryocytopoiesis. SeminHematol 2010; 47(3):281-8.
3. Roberts I, Murray NA. Neonatal thrombocytopenia.Semin Fetal Neonatal Med 2008;13(4):256-64.
4. Burrows RF, Kelton JG. Fetal thrombocytopenia and its relation to maternal thrombocytopenia. N Engl J Med 1993;329(20):1463-6.
5. Sainio S, Järvenpää AL, Renlund M, Riikonen S, Teramo K, Kekomäki R.
Thrombocytopenia in term infants: a population-based study. ObstetGynecol 2000;95(3):441-6..
6. Murray NA, Roberts IA. Circulating megakaryocytes and their progenitors in early thrombocytopenia in preterm neonates.Pediatr Res 1996;40(1):112-9.
7. Watts TL, Roberts IAG. Haematological abnormalities in the growth-restricted infant.SeminNeonatol 1999;4:41-54.
8. Roberts IAG, Murray NA. Neonatal thrombocytopenia: new insights into patho- genesis and implications for clinical management.CurrOpinPediatr 2001;13:16- 21.
9. Murray NA, Howarth LJ, McCloy MP, Letsky EA, Roberts IA. Platelet transfusion in the management of severe thrombocytopenia in neonatal intensive care unit patients.Transfus Med 2002;12(1):35-41.
10. Holzhauer S, Zieger B. Diagnosis and management of neonatal thrombocyto- penia. Semin Fetal Neonatal Med 2011;16(6):305-10.
11. LokeshwarR,BaydekarM,Kulkarini S. Neonatal thrombocytopenia_Achallenge.
Pediatriconcall journal 2012;4(2):36-56.
12. Baer VL, Lambert DK, Henry E, Christensen RD. Severe Thrombocytopenia in the NICU. Pediatrics 2009;124(6):e1095-100.
13. NaguriMH,MubaeieC,MathaeiH.Incidence of thrombocytopenia in the NICU.
Medical journal Armed Forces India 2011;1 67( 3): 234-236.
14. Jeremiah Z,Oburu J, Ruggeri M. Pattern and prevalence of neonatal thrombo- cytopenia in Port Harcourt Nijeria. Pathology and Laboratory Medicine Inter- national 2010;2: 27-31
15. Kusamsari N, Rohsiswatmo R, Gatot D. Incidence and risk factors of neonatal thrombocytopenia. Paediatr Indonesia 2010; 1: 50-60.
16. Henry E, Christensen R, Lambert DK. Severe thrombocytopenia in the NICU.
Pediatrics 2009;124:826-834
17. Bonifacio L, Petrova A, Nanjundaswamy S. Thrombocytopenia related neonatal outcome in preterms.Indian J Pediatr. 2007; 74: 269-274
18. Robert I, Murray NA. Neonatal thrombocytopenia Diagnosis and management.
Arch Dis Child Fetal Neonatal 2007;88: 359-364
19. Christensen RD, Henry E, Wiedmeier SE, Stoddard RA, Sola-Visner MC, Lam- bert DK, et al.
20. Thrombocytopenia among extremely low birth weight neonates: data from a multihospital healthcare system. J Perinatol 2006;26(6):348-53.
